Penetrating Atherosclerotic Ulcer

Summarized by: Niharika Shahi, M.D.

Reviewed by: Natasha Larocque, M.D.

Original publication details

Authors: Hideyuki Hayashi, Yohjiro Matsuoka, Ichiro Sakamoto, Eijun Sueyoshi, Tomoaki Okimoto, Kuniaki Hayashi, Naofumi Matsunaga

DOI: https://doi.org/10.1148/radiographics.20.4.g00jl01995

Reference: Hayashi, H., Matsuoka, Y., Sakamoto, I., Sueyoshi, E., Okimoto, T., Hayashi, K., & Matsunaga, N. (2000). Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept. Radiographics, 20(4), 995-1005.

Penetrating atherosclerotic ulcer:

Ulcerating atherosclerotic lesion that penetrates the elastic lamina and is associated with hematoma formation within the media of the aortic wall

Course

Initially develops in advanced atherosclerotic plaques, confined to the intimal layer

Progresses to deep ulcer that penetrates through lamina into the media

Penetrating atherosclerotic ulcer can lead to aortic dissection, aortic aneurysm, or rupture

Aortic dissection, which is defined as the penetration of the circulating blood into the wall of a vessel for a varying distance

Hematoma formation may extend along the media, resulting in either “double-barreled” or “thrombosed” aortic dissection

Double- barreled aortic dissection demonstrates communication between the true and false lumina, whereas thrombosed aortic dissection shows no opacification of the false lumen

In some cases, hematoma extension causes stretching of the weakened aortic wall, leading to the formation of a saccular aortic aneurysm

The aortic aneurysm and dissection may eventually rupture

Spontaneous rupture of the thoracic descending aorta is a rare condition that occurs in the absence of a true aneurysm

Although these ulcers occur in patients with advanced atherosclerosis, they are usually asymptomatic and confined to the intimal layer

Imaging

CT features of penetrating ulcers include focal involvement with adjacent subintimal hematoma located beneath the frequently calcified and inwardly displaced intima in the middle or distal third of the thoracic aorta

The ulcer is often associated with thickening or enhancement of the aortic wall

Atheromatous ulcers that are confined to the intimal layer sometimes appear radiologically similar to penetrating atherosclerotic ulcers

Although penetrating atherosclerotic ulcers typically involve the descending thoracic aorta, they can also involve the abdominal aorta, which is sometimes more severely atherosclerotic

Pertinent clinical and radiologic data should be monitored carefully during the first month after onset

Citation

Hayashi, H., Matsuoka, Y., Sakamoto, I., Sueyoshi, E., Okimoto, T., Hayashi, K., & Matsunaga, N. (2000). Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept. Radiographics, 20(4), 995-1005.